|
FAT EMULSION (NUTRILIPID OR INTRALIPID) BOLUS FROM BAG [4090000077]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0264446030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.42
|
| Rate for Payer: Aetna of WY Medicare |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.41
|
| Rate for Payer: Altius Commercial |
$0.41
|
| Rate for Payer: Beech Street Commercial |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.42
|
| Rate for Payer: Cigna of WY Commercial |
$0.42
|
| Rate for Payer: Entrust Commercial |
$0.41
|
| Rate for Payer: First Choice Health Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.25
|
| Rate for Payer: HealthUtah PPO |
$0.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.42
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.42
|
| Rate for Payer: PacificSource Commercial |
$0.39
|
| Rate for Payer: PHCS PPO |
$0.42
|
| Rate for Payer: Three Rivers PPO |
$0.32
|
| Rate for Payer: TriWest Veterans Administration |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.25
|
| Rate for Payer: WINHealth Partners Commercial |
$0.42
|
| Rate for Payer: Wise Provider Network Commercial |
$0.41
|
|
|
FAT EMULSION (NUTRILIPID OR INTRALIPID) BOLUS FROM BAG [4090000077]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0264446030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.41
|
| Rate for Payer: Altius Commercial |
$0.41
|
| Rate for Payer: Beech Street Commercial |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.42
|
| Rate for Payer: Cigna of WY Commercial |
$0.42
|
| Rate for Payer: Entrust Commercial |
$0.41
|
| Rate for Payer: First Choice Health Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.28
|
| Rate for Payer: HealthUtah PPO |
$0.43
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.42
|
| Rate for Payer: Multiplan Medicare/VA |
$0.27
|
| Rate for Payer: One Health Plan of WY PPO |
$0.42
|
| Rate for Payer: PacificSource Commercial |
$0.39
|
| Rate for Payer: PHCS PPO |
$0.42
|
| Rate for Payer: Three Rivers PPO |
$0.32
|
| Rate for Payer: TriWest Veterans Administration |
$0.28
|
| Rate for Payer: United Healthcare Commercial |
$0.37
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
| Rate for Payer: WINHealth Partners Commercial |
$0.41
|
| Rate for Payer: Wise Provider Network Commercial |
$0.41
|
|
|
FECAL BLOOD SCRN IMMUNOASSAY
|
Professional
|
Both
|
$143.00
|
|
|
Service Code
|
HCPCS G0328
|
| Hospital Charge Code |
G0328
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Aetna of WY Medicare |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$135.85
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: First Choice Health Commercial |
$128.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.05
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: Multiplan Medicare/VA |
$15.34
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$135.85
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: TriWest Veterans Administration |
$18.05
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: United Healthcare Medicare |
$18.05
|
| Rate for Payer: WINHealth Partners Commercial |
$135.85
|
|
|
FECAL GLOBIN BY IMMUNOCHEMISTRY (FIT)
|
Professional
|
Both
|
$143.00
|
|
|
Service Code
|
HCPCS 82274
|
| Hospital Charge Code |
82274
|
| Min. Negotiated Rate |
$13.53 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Aetna of WY Medicare |
$15.92
|
| Rate for Payer: Beech Street Commercial |
$135.85
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: First Choice Health Commercial |
$128.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.92
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: Multiplan Medicare/VA |
$13.53
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$135.85
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: TriWest Veterans Administration |
$15.92
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: United Healthcare Medicare |
$15.92
|
| Rate for Payer: WINHealth Partners Commercial |
$135.85
|
|
|
FEEDING TUBE 10FR 43" DOBBHOFF
|
Facility
|
OP
|
$33.48
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.45 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.81
|
| Rate for Payer: Aetna of WY Medicare |
$22.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.14
|
| Rate for Payer: Altius Commercial |
$32.14
|
| Rate for Payer: Beech Street Commercial |
$32.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.49
|
| Rate for Payer: Cash Price |
$23.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.48
|
| Rate for Payer: Cigna of WY Commercial |
$32.81
|
| Rate for Payer: Entrust Commercial |
$31.81
|
| Rate for Payer: First Choice Health Commercial |
$31.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.42
|
| Rate for Payer: HealthUtah PPO |
$33.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.48
|
| Rate for Payer: Multiplan Medicare/VA |
$18.45
|
| Rate for Payer: One Health Plan of WY PPO |
$32.81
|
| Rate for Payer: PacificSource Commercial |
$30.13
|
| Rate for Payer: PHCS PPO |
$32.81
|
| Rate for Payer: Three Rivers PPO |
$25.11
|
| Rate for Payer: TriWest Veterans Administration |
$19.42
|
| Rate for Payer: United Healthcare Commercial |
$29.13
|
| Rate for Payer: United Healthcare Medicare |
$19.42
|
| Rate for Payer: WINHealth Partners Commercial |
$32.81
|
| Rate for Payer: Wise Provider Network Commercial |
$31.81
|
|
|
FEEDING TUBE 10FR 43" DOBBHOFF
|
Facility
|
IP
|
$33.48
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.99 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$32.14
|
| Rate for Payer: Altius Commercial |
$32.14
|
| Rate for Payer: Beech Street Commercial |
$32.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$27.49
|
| Rate for Payer: Cash Price |
$23.44
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.48
|
| Rate for Payer: Cigna of WY Commercial |
$32.81
|
| Rate for Payer: Entrust Commercial |
$31.81
|
| Rate for Payer: First Choice Health Commercial |
$31.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.10
|
| Rate for Payer: HealthUtah PPO |
$33.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.48
|
| Rate for Payer: Multiplan Medicare/VA |
$20.99
|
| Rate for Payer: One Health Plan of WY PPO |
$32.81
|
| Rate for Payer: PacificSource Commercial |
$30.13
|
| Rate for Payer: PHCS PPO |
$32.81
|
| Rate for Payer: Three Rivers PPO |
$25.11
|
| Rate for Payer: TriWest Veterans Administration |
$22.10
|
| Rate for Payer: United Healthcare Commercial |
$29.13
|
| Rate for Payer: United Healthcare Medicare |
$22.10
|
| Rate for Payer: WINHealth Partners Commercial |
$31.81
|
| Rate for Payer: Wise Provider Network Commercial |
$31.81
|
|
|
FEEDING TUBE 8FR 55" DOBBHOFF
|
Facility
|
OP
|
$30.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.60 |
| Max. Negotiated Rate |
$30.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.52
|
| Rate for Payer: Aetna of WY Medicare |
$19.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.92
|
| Rate for Payer: Altius Commercial |
$28.92
|
| Rate for Payer: Beech Street Commercial |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.73
|
| Rate for Payer: Cash Price |
$21.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.22
|
| Rate for Payer: Cigna of WY Commercial |
$29.52
|
| Rate for Payer: Entrust Commercial |
$28.61
|
| Rate for Payer: First Choice Health Commercial |
$28.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.47
|
| Rate for Payer: HealthUtah PPO |
$30.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.22
|
| Rate for Payer: Multiplan Medicare/VA |
$16.60
|
| Rate for Payer: One Health Plan of WY PPO |
$29.52
|
| Rate for Payer: PacificSource Commercial |
$27.11
|
| Rate for Payer: PHCS PPO |
$29.52
|
| Rate for Payer: Three Rivers PPO |
$22.59
|
| Rate for Payer: TriWest Veterans Administration |
$17.47
|
| Rate for Payer: United Healthcare Commercial |
$26.20
|
| Rate for Payer: United Healthcare Medicare |
$17.47
|
| Rate for Payer: WINHealth Partners Commercial |
$29.52
|
| Rate for Payer: Wise Provider Network Commercial |
$28.61
|
|
|
FEEDING TUBE 8FR 55" DOBBHOFF
|
Facility
|
IP
|
$30.12
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.89 |
| Max. Negotiated Rate |
$30.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$28.92
|
| Rate for Payer: Altius Commercial |
$28.92
|
| Rate for Payer: Beech Street Commercial |
$29.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.73
|
| Rate for Payer: Cash Price |
$21.09
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.22
|
| Rate for Payer: Cigna of WY Commercial |
$29.52
|
| Rate for Payer: Entrust Commercial |
$28.61
|
| Rate for Payer: First Choice Health Commercial |
$28.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.88
|
| Rate for Payer: HealthUtah PPO |
$30.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.22
|
| Rate for Payer: Multiplan Medicare/VA |
$18.89
|
| Rate for Payer: One Health Plan of WY PPO |
$29.52
|
| Rate for Payer: PacificSource Commercial |
$27.11
|
| Rate for Payer: PHCS PPO |
$29.52
|
| Rate for Payer: Three Rivers PPO |
$22.59
|
| Rate for Payer: TriWest Veterans Administration |
$19.88
|
| Rate for Payer: United Healthcare Commercial |
$26.20
|
| Rate for Payer: United Healthcare Medicare |
$19.88
|
| Rate for Payer: WINHealth Partners Commercial |
$28.61
|
| Rate for Payer: Wise Provider Network Commercial |
$28.61
|
|
|
FEMOSTOP GOLD ABBOT
|
Facility
|
OP
|
$315.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$173.56 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$308.70
|
| Rate for Payer: Aetna of WY Medicare |
$207.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$302.40
|
| Rate for Payer: Altius Commercial |
$302.40
|
| Rate for Payer: Beech Street Commercial |
$308.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$258.62
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$305.55
|
| Rate for Payer: Cigna of WY Commercial |
$308.70
|
| Rate for Payer: Entrust Commercial |
$299.25
|
| Rate for Payer: First Choice Health Commercial |
$299.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$299.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$182.70
|
| Rate for Payer: HealthUtah PPO |
$315.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$305.55
|
| Rate for Payer: Multiplan Medicare/VA |
$173.56
|
| Rate for Payer: One Health Plan of WY PPO |
$308.70
|
| Rate for Payer: PacificSource Commercial |
$283.50
|
| Rate for Payer: PHCS PPO |
$308.70
|
| Rate for Payer: Three Rivers PPO |
$236.25
|
| Rate for Payer: TriWest Veterans Administration |
$182.70
|
| Rate for Payer: United Healthcare Commercial |
$274.05
|
| Rate for Payer: United Healthcare Medicare |
$182.70
|
| Rate for Payer: WINHealth Partners Commercial |
$308.70
|
| Rate for Payer: Wise Provider Network Commercial |
$299.25
|
|
|
FEMOSTOP GOLD ABBOT
|
Facility
|
IP
|
$315.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.50 |
| Max. Negotiated Rate |
$315.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$308.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$302.40
|
| Rate for Payer: Altius Commercial |
$302.40
|
| Rate for Payer: Beech Street Commercial |
$308.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$258.62
|
| Rate for Payer: Cash Price |
$220.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$305.55
|
| Rate for Payer: Cigna of WY Commercial |
$308.70
|
| Rate for Payer: Entrust Commercial |
$299.25
|
| Rate for Payer: First Choice Health Commercial |
$299.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$299.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$207.90
|
| Rate for Payer: HealthUtah PPO |
$315.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$305.55
|
| Rate for Payer: Multiplan Medicare/VA |
$197.50
|
| Rate for Payer: One Health Plan of WY PPO |
$308.70
|
| Rate for Payer: PacificSource Commercial |
$283.50
|
| Rate for Payer: PHCS PPO |
$308.70
|
| Rate for Payer: Three Rivers PPO |
$236.25
|
| Rate for Payer: TriWest Veterans Administration |
$207.90
|
| Rate for Payer: United Healthcare Commercial |
$274.05
|
| Rate for Payer: United Healthcare Medicare |
$207.90
|
| Rate for Payer: WINHealth Partners Commercial |
$299.25
|
| Rate for Payer: Wise Provider Network Commercial |
$299.25
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [41966]
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 0378306677
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.51
|
| Rate for Payer: Altius Commercial |
$2.51
|
| Rate for Payer: Beech Street Commercial |
$2.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.14
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.53
|
| Rate for Payer: Cigna of WY Commercial |
$2.56
|
| Rate for Payer: Entrust Commercial |
$2.48
|
| Rate for Payer: First Choice Health Commercial |
$2.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.72
|
| Rate for Payer: HealthUtah PPO |
$2.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.53
|
| Rate for Payer: Multiplan Medicare/VA |
$1.64
|
| Rate for Payer: One Health Plan of WY PPO |
$2.56
|
| Rate for Payer: PacificSource Commercial |
$2.35
|
| Rate for Payer: PHCS PPO |
$2.56
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.72
|
| Rate for Payer: United Healthcare Commercial |
$2.27
|
| Rate for Payer: United Healthcare Medicare |
$1.72
|
| Rate for Payer: WINHealth Partners Commercial |
$2.48
|
| Rate for Payer: Wise Provider Network Commercial |
$2.48
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [41966]
|
Facility
|
IP
|
$12.37
|
|
|
Service Code
|
NDC 6068762911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.76 |
| Max. Negotiated Rate |
$12.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.88
|
| Rate for Payer: Altius Commercial |
$11.88
|
| Rate for Payer: Beech Street Commercial |
$12.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.16
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.00
|
| Rate for Payer: Cigna of WY Commercial |
$12.12
|
| Rate for Payer: Entrust Commercial |
$11.75
|
| Rate for Payer: First Choice Health Commercial |
$11.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.16
|
| Rate for Payer: HealthUtah PPO |
$12.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.00
|
| Rate for Payer: Multiplan Medicare/VA |
$7.76
|
| Rate for Payer: One Health Plan of WY PPO |
$12.12
|
| Rate for Payer: PacificSource Commercial |
$11.13
|
| Rate for Payer: PHCS PPO |
$12.12
|
| Rate for Payer: Three Rivers PPO |
$9.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.16
|
| Rate for Payer: United Healthcare Commercial |
$10.76
|
| Rate for Payer: United Healthcare Medicare |
$8.16
|
| Rate for Payer: WINHealth Partners Commercial |
$11.75
|
| Rate for Payer: Wise Provider Network Commercial |
$11.75
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [41966]
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
NDC 0378306677
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.56
|
| Rate for Payer: Aetna of WY Medicare |
$1.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.51
|
| Rate for Payer: Altius Commercial |
$2.51
|
| Rate for Payer: Beech Street Commercial |
$2.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.14
|
| Rate for Payer: Cash Price |
$1.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.53
|
| Rate for Payer: Cigna of WY Commercial |
$2.56
|
| Rate for Payer: Entrust Commercial |
$2.48
|
| Rate for Payer: First Choice Health Commercial |
$2.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.51
|
| Rate for Payer: HealthUtah PPO |
$2.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.53
|
| Rate for Payer: Multiplan Medicare/VA |
$1.44
|
| Rate for Payer: One Health Plan of WY PPO |
$2.56
|
| Rate for Payer: PacificSource Commercial |
$2.35
|
| Rate for Payer: PHCS PPO |
$2.56
|
| Rate for Payer: Three Rivers PPO |
$1.96
|
| Rate for Payer: TriWest Veterans Administration |
$1.51
|
| Rate for Payer: United Healthcare Commercial |
$2.27
|
| Rate for Payer: United Healthcare Medicare |
$1.51
|
| Rate for Payer: WINHealth Partners Commercial |
$2.56
|
| Rate for Payer: Wise Provider Network Commercial |
$2.48
|
|
|
FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET [41966]
|
Facility
|
OP
|
$12.37
|
|
|
Service Code
|
NDC 6068762911
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$12.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.12
|
| Rate for Payer: Aetna of WY Medicare |
$8.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.88
|
| Rate for Payer: Altius Commercial |
$11.88
|
| Rate for Payer: Beech Street Commercial |
$12.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.16
|
| Rate for Payer: Cash Price |
$8.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.00
|
| Rate for Payer: Cigna of WY Commercial |
$12.12
|
| Rate for Payer: Entrust Commercial |
$11.75
|
| Rate for Payer: First Choice Health Commercial |
$11.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.17
|
| Rate for Payer: HealthUtah PPO |
$12.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.00
|
| Rate for Payer: Multiplan Medicare/VA |
$6.82
|
| Rate for Payer: One Health Plan of WY PPO |
$12.12
|
| Rate for Payer: PacificSource Commercial |
$11.13
|
| Rate for Payer: PHCS PPO |
$12.12
|
| Rate for Payer: Three Rivers PPO |
$9.28
|
| Rate for Payer: TriWest Veterans Administration |
$7.17
|
| Rate for Payer: United Healthcare Commercial |
$10.76
|
| Rate for Payer: United Healthcare Medicare |
$7.17
|
| Rate for Payer: WINHealth Partners Commercial |
$12.12
|
| Rate for Payer: Wise Provider Network Commercial |
$11.75
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
NDC 4778142311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.80
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$25.46
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$26.80
|
| Rate for Payer: WINHealth Partners Commercial |
$38.57
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
NDC 4778142311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Aetna of WY Medicare |
$26.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.55
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$22.37
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$23.55
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$23.55
|
| Rate for Payer: WINHealth Partners Commercial |
$39.79
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
NDC 0378911916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.80
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$25.46
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$26.80
|
| Rate for Payer: WINHealth Partners Commercial |
$38.57
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
NDC 4778142347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.80
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$25.46
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$26.80
|
| Rate for Payer: WINHealth Partners Commercial |
$38.57
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
NDC 0378911916
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Aetna of WY Medicare |
$26.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.55
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$22.37
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$23.55
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$23.55
|
| Rate for Payer: WINHealth Partners Commercial |
$39.79
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
NDC 0406911276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.80
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$25.46
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$26.80
|
| Rate for Payer: WINHealth Partners Commercial |
$38.57
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
NDC 0406911276
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Aetna of WY Medicare |
$26.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.55
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$22.37
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$23.55
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$23.55
|
| Rate for Payer: WINHealth Partners Commercial |
$39.79
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
NDC 0378911998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Aetna of WY Medicare |
$26.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.55
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$22.37
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$23.55
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$23.55
|
| Rate for Payer: WINHealth Partners Commercial |
$39.79
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
IP
|
$40.60
|
|
|
Service Code
|
NDC 0378911998
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.46 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.80
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$25.46
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$26.80
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$26.80
|
| Rate for Payer: WINHealth Partners Commercial |
$38.57
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 12 MCG/HR TRANSDERMAL PATCH [38542]
|
Facility
|
OP
|
$40.60
|
|
|
Service Code
|
NDC 4778142347
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.37 |
| Max. Negotiated Rate |
$40.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.79
|
| Rate for Payer: Aetna of WY Medicare |
$26.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.98
|
| Rate for Payer: Altius Commercial |
$38.98
|
| Rate for Payer: Beech Street Commercial |
$39.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.33
|
| Rate for Payer: Cash Price |
$28.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.38
|
| Rate for Payer: Cigna of WY Commercial |
$39.79
|
| Rate for Payer: Entrust Commercial |
$38.57
|
| Rate for Payer: First Choice Health Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.55
|
| Rate for Payer: HealthUtah PPO |
$40.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.38
|
| Rate for Payer: Multiplan Medicare/VA |
$22.37
|
| Rate for Payer: One Health Plan of WY PPO |
$39.79
|
| Rate for Payer: PacificSource Commercial |
$36.54
|
| Rate for Payer: PHCS PPO |
$39.79
|
| Rate for Payer: Three Rivers PPO |
$30.45
|
| Rate for Payer: TriWest Veterans Administration |
$23.55
|
| Rate for Payer: United Healthcare Commercial |
$35.32
|
| Rate for Payer: United Healthcare Medicare |
$23.55
|
| Rate for Payer: WINHealth Partners Commercial |
$39.79
|
| Rate for Payer: Wise Provider Network Commercial |
$38.57
|
|
|
FENTANYL 25 MCG/HR TRANSDERMAL PATCH [17570]
|
Facility
|
IP
|
$24.95
|
|
|
Service Code
|
NDC 0406912576
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.64 |
| Max. Negotiated Rate |
$24.95 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.95
|
| Rate for Payer: Altius Commercial |
$23.95
|
| Rate for Payer: Beech Street Commercial |
$24.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.48
|
| Rate for Payer: Cash Price |
$17.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.20
|
| Rate for Payer: Cigna of WY Commercial |
$24.45
|
| Rate for Payer: Entrust Commercial |
$23.70
|
| Rate for Payer: First Choice Health Commercial |
$23.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.47
|
| Rate for Payer: HealthUtah PPO |
$24.95
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.20
|
| Rate for Payer: Multiplan Medicare/VA |
$15.64
|
| Rate for Payer: One Health Plan of WY PPO |
$24.45
|
| Rate for Payer: PacificSource Commercial |
$22.46
|
| Rate for Payer: PHCS PPO |
$24.45
|
| Rate for Payer: Three Rivers PPO |
$18.71
|
| Rate for Payer: TriWest Veterans Administration |
$16.47
|
| Rate for Payer: United Healthcare Commercial |
$21.71
|
| Rate for Payer: United Healthcare Medicare |
$16.47
|
| Rate for Payer: WINHealth Partners Commercial |
$23.70
|
| Rate for Payer: Wise Provider Network Commercial |
$23.70
|
|
